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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THINS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IZ '] <br /> i (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5080 E. Peltier Rd. - in yard CENSUS TRACT <br /> Owner's Name JAMES SHINOZAKI Phone <br /> Address 5080 E. Peltier Rd. City <br /> Contractor's Name GOEHRING PUMP & IRRIGATION INC. License 309031 Phone <br /> 727-5548 <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> AL <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT �LT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMES'T'IC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 1` <br /> Domestic/private i Drilled Dia, of Well Casing <br />!- �==-;Domestic ./R ublic —Dr.iuen -. �•�. <br /> �GaugeYof.�Casing;:��-_— <br /> Irrigation -•-•�-�-;--�--�-Grave'DPack-*� Dep-th-of.--Grout-S-eal— � <br /> Cathodic Protection I Rotary Type of Grout � y <br /> Disposal t Other Ota.Information <br /> Geophysical ` '' ` '^'Surftac� Seal Installed By: <br />' PUMP INS&LLATION: Contractor ` <br /> H.P. <br /> ,y <br /> PUMP REPLACEMENT: / / State Work Done " <br /> PUMP .REPAIR: I/ State Work Done added n <br /> _ <br /> �Pornona pump- d _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ` <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the wellin use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G AND A FINAL iINSPECTION. <br /> SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />.APPLICATION ACCEPTED BY DATE -Z 7 z <br /> iADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />, INSPECTION BY DATE INSPECTION BY DATE <br />{ � I <br /> E E H 1426 Rev. 1--74 � Z7. - 2H <br />